The Australian Transport Safety Bureau (ATSB) is Australia's national transport safety investigator. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport. The ATSB is Australia's prime agency for the independent investigation of civil aviation, rail and maritime accidents, incidents and safety deficiencies.

Analysis

Summary

The procedural controller was responsible for issuing clearances to aircraft under procedural control, as was the case in this event. The role of the radar controller was to pass on the clearance to the aircraft. By not consulting with the procedural controller, the radar controller bypassed the established system of control, leading to a breakdown in safety.

The configuration of the Sector 3 console provided insufficient space to adequately display all relevant flight progress strips. As a result, controllers had developed the habit of removing strips at the earliest opportunity, thereby creating the potential for vital information to be missed.

The KANTO flight progress strip for KAL362 should have been retained on the procedural board until the crew reported at SINMA, the next position. The removal of the KANTO strip by the radar controller removed the only reminder available to all controllers that the intended tracks of KAL362 and QFI6 would cross.

Inclusion of the KATKI position on all flight progress strips for aircraft using the intersecting routes would have enabled controllers to more readily assess separation requirements in the procedural airspace. If the strips had required the KATKI position it is probable that the details for QFI6 and KAL362 would have been displayed under the same designator on the board, allowing controllers to recognise the potential conflict.

The inability to monitor the control frequency while conducting coordination reduced the likelihood of the procedural controller maintaining a complete appreciation of the disposition of traffic.

The reason why the crew of QFI6 did not hear the transmissions regarding KAL362 climbing to the same level, while operating on the same frequency within direct line of sight, could not be determined.